Provider Demographics
NPI:1942249792
Name:AN, SEUNG ROG (MD)
Entity Type:Individual
Prefix:DR
First Name:SEUNG
Middle Name:ROG
Last Name:AN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALBERT
Other - Middle Name:SEUNGROG
Other - Last Name:AN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2655 W. OLYMPIC BLVD.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006
Mailing Address - Country:US
Mailing Address - Phone:213-388-7887
Mailing Address - Fax:213-388-3504
Practice Address - Street 1:2655 W. OLYMPIC BLVD.
Practice Address - Street 2:SUITE 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006
Practice Address - Country:US
Practice Address - Phone:213-388-7887
Practice Address - Fax:213-388-3504
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090160Medicaid
CA00A425660Medicaid
CAW15186Medicare ID - Type UnspecifiedNHIC GROUP NUMBER
CA00A425660Medicaid
CAGR0090160Medicaid